Clinical Compliance Auditor

This is a fully remote position, open to applicants in Texas.

📋 Description

• Execute thorough clinical compliance audits that encompass utilization management, denial documentation, clinical reporting, authorization compliance, and requirements for delegated services.

• Oversee compliance with UM and PHM Plans, Managed Services Agreements, as well as contractual and regulatory obligations specific to clients.

• Conduct regular, scheduled, and ad hoc audits.

• Act as a secondary reviewer for denial documentation.

• Track audit findings, clinical workflows, and reporting processes to detect trends, risks, documentation shortcomings, and process deficiencies.

• Create and sustain audit tools, protocols, compliance monitoring frameworks, UM and PHM Plans, along with clinical compliance procedures.

• Offer mentorship, direction, and subject matter expertise to Clinical Compliance Auditors and clinical operations personnel.

• Assist leadership in pinpointing training needs and opportunities for clinical compliance enhancements.

• Coordinate audit reviews, reporting processes, and support activities for compliance committees.

• Examine audit outcomes and clinical data to uncover trends, root causes, and areas for improvement.

• Prepare and deliver audit findings and compliance reports to clinical leadership and operational stakeholders.

• Aid in the development of reporting tools, dashboards, and audit metrics.

• Adjust to changing business requirements and assist cross-functional initiatives.

• Adhere to security policies and procedures to safeguard PHI, PII, and Guidehealth intellectual property.

⛳️ Requirements

• A valid, unrestricted Registered Nurse (RN) license is mandatory.

• A minimum of 3–5 years of experience in utilization management, clinical auditing, clinical compliance, or managed care is required.

• At least 2 years of experience in clinical compliance auditing or healthcare auditing is essential.

• Strong understanding of utilization management processes, clinical documentation, and regulatory compliance requirements is necessary.

• Familiarity with Medicare, commercial managed care, and compliance requirements for delegated services is expected.

• Excellent analytical, critical thinking, and problem-solving abilities are required.

• Capability to work autonomously and apply sound professional judgment is essential.

• Exceptional written and verbal communication skills are a must.

• Proficiency in Microsoft Office applications, including Excel, Word, and reporting tools is required.

• Must be able to provide a personal internet connection with a minimum of 100 Mbps download and 10 Mbps upload speed.

• Availability during designated working hours is essential.

• Willingness to participate in virtual meetings with the camera on is required.

🏝️ Benefits

• Fully remote work setup.

• Necessary work equipment is supplied at no cost.

• Comprehensive Medical, Dental, and Vision plans.

• 401(k) plan featuring a 3% employer match on a 6% contribution.

• Life and Disability insurance options.

• Voluntary Life insurance choices available.

• Employee Assistance Program (EAP).

• Paid time off benefits.

• Paid parental leave.

• Access to learning and development resources.

• Flexible work-life balance.

• Extensive benefits package for eligible full-time employees working 30+ hours per week.